Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Rebate Application Form <br />Property O�.vner Name: _�F`,- E- i �%�w�'h'� 2� <br />InstallationAddress: J'`1�Z 011K(S i�✓� <br />City: �L�C'�ZFT Sta�e: LJA _ 2ip:�` Za / - <br />I tvlailiny Address (il dil(erent): <br />City: <br />Stale: <br />Email. --- Phone: (y7.$j yi3�-`7�i_- <br />� Total Cost to Install Device (/rom confrar,7or invoice): S a�a �� g� <br />Please verify the following: <br />�I am the ovmer of the property �vhere Ihe backv�ater prevention device �vas ins�alled. <br />�I worked �vith lhe conlractor to determine the location for Ihe back�vater prevention dewce and <br />understand that the decision reyarding lhe locatian of the device was minc <br />`�My coNraclor instruc�ed me how to access, inspecl, and mainlain the device. <br />;� I undersland lhat I am responsible for mainlaining lhe backwaler prevention device and keeping <br />it in good working order, unless it is installed in Ihe city nght-of-�vay. <br />( J� If i sell my property, I will make polentiai buyers aware of the backe�ater prevention device and <br />the need lo inspecl and maintain it on a rogular hass. <br />(� I am enclosing ail ot Ihe necessary papenvork (use Ihe yello�.v Rebale Submdlal Checklist). <br />Select from the following: <br />(] The conlractor idenlified dov;nspouts or olher dr�inac�e Ilines lhal tivere connecled lo my se�vor <br />hne (betwcen my house and the inslalled device) and removed, or rerouled �hem. <br />�To my knotivledge, my property has no do�vnspouts or other drainage con�ected to my sewer line <br />(between my house and Ihe installed device). <br />[� There are do�vnspouts or other drainage lines connecled to my sewer Ime (belv��een my house <br />and the installed devicc). I understand thal leaving these conneclions creates a nsk o( flooding <br />and I accepl Qial risk. <br />Signature�f �'�i�=�� lN'�Ji�,��.�' _ Date ,�-/7" ��� <br />�_. <br />